MassHealth
Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
www.mass.gov/masshealth
MassHealth
Acute Inpatient Hospital Bulletin 142
November 2011
TO: Acute Inpatient Hospitals Participating in MassHealth
FROM: Julian J. Harris, M.D., Medicaid Director
RE: Revisions to the Medical Benefit Request, the Senior Medical Benefit
Request, Other Forms, and the Virtual Gateway
Background
MassHealth has revised the Medical Benefit Request (MBR), the Senior
Medical Benefit Request (SMBR), and other related forms to clarify policy
and capture applicant information to appropriately determine eligibility for
individuals who are visitors to Massachusetts. In addition, there are
changes to clarify current policy and to the format of the forms. As a
result, MA21, the Virtual Gateway (VG) Common Application, and
MassHealth notices have been revised.
These changes are effective October 1, 2011.
Changes to the MBR, SMBR, and the VG
Revisions common to the MBR and the SMBR
* Visitor section: This section was removed and was replaced with a
new section about residency.
* Residency section: A new section was added to determine whether
individuals who are applying for benefits are residents of
Massachusetts and if they intend to remain in the state.
* Health Insurance You Have Now and Subsidized Health
Insurance You May Be Eligible For sections: All references to the
Fishing Partnership Health Plan (FPHP) were removed.
o In Part A – Health Insurance You Have Now: The FPHP was
removed as an insurance-type option.
o In Part B – Subsidized Insurance You May Be Eligible For: The
question about income from the commercial fishing industry was
removed.
* Signature page: Language was added to ensure that the individuals
signing the application are aware that the signature certifies the
correctness of not only the application and the supplements submitted
in conjunction with the application, but also the correctness of any
other documents and forms that are submitted or required by
MassHealth.
Revisions unique to the MBR
* Instructions – first page: There are minor formatting changes and
(cont.) grammatical corrections.
* Instructions – second page: A reference to the FPHP was removed.
* American Indian/Native American section: The section was
relocated and both the statement and the question were updated.
* Supplement B: Absent Parent Questions and Assignment of
Rights: The language in the third line of instructions at the top of the
first page was updated to include specific instructions to sign Part E
(signature section). In addition, the language in Part E was revised.
Revisions unique to the SMBR
* Instructions – second page: The mailing addresses have been
changed to advise applicants where to submit an application. The
addresses are based on the type of benefits requested.
o Applications for benefits for those living in the community
(including those applying for waiver benefits, such as Frail Elder,
Kaleigh Mulligan, and PACE) should be mailed to the Central
Processing Unit (CPU) in Charlestown.
o Applications for long-term-care services in long-term-care facilities
should be mailed to the MassHealth Enrollment Center (MEC) that
is closest to where the facility is located.
* American Indian/Alaska Native section: This section was added to
the application.
Virtual Gateway Revisions
The Virtual Gateway has been updated to include all of the changes and
additions for the MBR and the SMBR (with the exception of mailing
addresses for individuals who need long-term-care services in a longterm-
care facility).
Related Forms
Absent-Parent Questions and Assignment of Rights (AP-1)
This stand-alone form has been updated with the same changes as the
Supplement B: Absent-Parent Questions and Assignment of Rights in the
MBR.
Long-Term-Care Supplement (LTC-SUPP)
This stand-alone form has been updated to include the mailing addresses
that mimic the mailing addresses located on the instruction pages of the
SMBR.
Eligibility Representative Designation Form (ERD)
* What an eligibility representative does section: The reference to
the Uncompensated Care Pool (former name of the Health Safety
Net) was removed.
* Where to send the form section: This form has been updated to
include the various mailing addresses.
MassHealth Buy-In application and instructions (MHBI-1 and MHBI-2)
This application has been updated to include a different mailing address
(CPU in Charlestown).
Annual Review Forms (ERVs and MERs)
The eligibility review forms are being revised to add the absent parent
changes (ERVs) and the updated signature page information (ERVs and
MERs).
Residency Information
The residency question asks individuals if they are residents of
Massachusetts and if they intend to remain in the state. It will be used to
identify those individuals who may be eligible for benefits and those who
do not meet the criteria. This information must be completed on all
applications before MassHealth can process the application.
Proof of Residency
If there is any question of residency, such as conflicting or contradictory
information about the applicant’s declared place of residence,
MassHealth may ask the applicant to provide proof of residency. If proof
of residency is required, MassHealth will send a request for information
(verification) notice. The applicant will have 60 days (if under age 65) or
30 days (if aged 65 or older) to submit the documentation. The notice will
identify the types of documents that can be submitted to prove
Massachusetts residency. The acceptable documentation includes the
following.
* For adults
o lease or mortgage statement;
o city or town real-estate tax bill;
o rent receipt;
o current utility bill;
o statement from a shelter; or
o notarized affidavit supporting residency
* For children
o school records;
o nursery-school or day-care records; or
o notarized affidavit supporting residency
Suspected Fraud
If an individual who is helping an applicant complete an application
suspects that the applicant is providing fraudulent information, the
assisting individual should process the application and then report the
suspected fraud to MassHealth by calling the MassHealth Fraud Hotline
at 1-877-4FRAUD-0 (1-877-437-2830). The assisting individual should
provide any information that would help MassHealth investigate the issue,
such as the applicant’s name, address, date of birth, social security
number (if available), the reason for the suspected fraud, and the
application information (such as the date submitted or the application
number).
Changes about American Indians and Alaska Natives
American Indians and Alaska Natives who are eligible for or who have
ever received an item or service furnished by the Indian Health Service,
and Alaska Natives an Indian tribe, a tribal organization, or an urban Indian
organization, or from a non-Indian health-care provider through a referral from
an Indian health-care provider are exempt from paying copayments and premiums
as MassHealth members.
This update eliminates the portion of the question that asked only for
those American Indians and Alaska Natives under age 19. The policy now
applies to all American Indians and Alaska Natives regardless of age.
Supplies and Use of Outdated Forms
Supplies of the revised forms are now available. To order supplies, call 1-800-
841-2900 or e-mail your request to publications@mahealth.net.
MassHealth will continue to accept the previous version of these forms
until supplies are exhausted. MassHealth will convert the “visitor”
responses to the new “residency” responses based on how the applicant
answers the “visitor” questions.
Questions
If you have any questions about the information in this bulletin, please
contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to
providersupport@mahealth.net, or fax your inquiry to 617-988-8974.